U.S. Psyche Bedevils Health Effort

By

Gerald F. Seib

Updated Aug. 4, 2009 12:01 a.m. ET

I hate the health-care system -- but don't you dare mess with it.

That's a pretty apt summary of the American mind-set about health care -- and not just now, but for decades. Something about health care calls forth from the national psyche a deep, almost inexplicable schizophrenia, as the latest, delayed effort to "reform" health care is showing President Barack Obama and the rest of Washington.

Indeed, the quest to fix health care has bedeviled every president since Harry Truman. Arguably, only one -- Lyndon Johnson, when he oversaw the birth of Medicare -- succeeded in making a real dent. Mr. Obama and Congress have, of course, spent much of the summer agonizing over how to alter the system, but this week lawmakers will head home for an August recess without having passed anything in either the House or Senate, largely because of public anxieties.

This seems counterintuitive. People know the system is creaking, frustrating and way too expensive. They complain about it all the time. Yet they can't quite let it go.

Why? Like health care itself, the answer is complicated. But there are five big reasons:

The Marcus Welby factor. Americans maintain a gauzy, almost dreamy image of doctors and nurses. The image of the preternaturally soothing hometown doctor portrayed on television's "Marcus Welby, M.D." is the ideal to which Americans cling.

The clinical discussions of cost-effectiveness, reimbursement rates, insurance exchanges and "best practices" that go along with the health debate are wholly at odds with this image of tailored medical care. Even though today's cost pressures already are slowly strangling Dr. Welby, Americans fear that changes to the system that created him might hasten the process. "Health care is intensely personal," says Bill McInturff, a Republican pollster who co-directs the Wall Street Journal/NBC News poll and has long studied attitudes about health care. "It's not like welfare. It's about me."

The Rube Goldberg Factor. The very fact that the current system is like one of those overly complicated machines means Americans have no earthly idea how much they're paying for health care, which is even more costly than most realize. Thus, they are stunned when confronted with reform plans that lay out the costs -- not just the new ones, but the existing ones. They get sticker shock.

"So much of the cost of health care is submerged, is invisible, that merely raising it to the surface creates opposition," says Paul Starr, a Princeton University sociologist who advised the Clinton administration's health-overhaul effort. "It's very hard for people to evaluate the alternatives being discussed because they don't understand how expensive it [already] is."

The Company-Town Factor. It's mostly an accident of history that America has a health-care system in which employers pay most of the cost of insurance. It does so in large measure because the government decided to exempt health insurance from wage and price controls during World War II. That meant companies couldn't give raises to attract workers but could offer health benefits to do so. Then Uncle Sam decided that neither employers nor employees had to pay payroll taxes on the money spent on health benefits, thereby enshrining health insurance as the leading employee benefit.

That, in turn, has fostered a view of employers as either paternalistic guardians who look after our health for mutual benefit, or as powerful overlords with an obligation to do so. Either way, there now is a deep fear of both the notion that individuals would be better off fending for themselves (the conservative impulse) or that government ought to take over the job (the liberal impulse). Those are the two starkest alternatives to the status quo, and both scare people.

The Post Office Factor. Americans are deeply cynical about government's ability to do anything right. Putting a man on the moon, building an interstate-highway system, fielding history's most lethal army -- nothing has changed that. Even Mr. Obama makes jokes about how standing in line at the post office has convinced him he doesn't want the government running private firms.

Yet a health overhaul inevitably involves a bigger role for government in, if nothing else, setting standards and policing the market. And that's where lots of Americans fall off the reform bandwagon. A survey this summer by the Gallup polling organization, which regularly tests confidence in American institutions, illustrates the problem. Some 36% expressed confidence in the medical system, ranking it in the middle of the broad range of American institutions that were tested. But a mere 17% said they have confidence in Congress, which is where any health overhaul would be created, putting lawmakers second from the bottom on Gallup's list (just a whisker above big business).

The Job-Machine Factor. This is a vastly underappreciated element of the national psyche. The health system isn't just something that provides medical care; it's now also the largest industry in the land. It provides more than 14 million jobs, the Bureau of Labor Statistics tells us, and seven of the 20 fastest-growing occupations are health-related. More than that, health care will generate a staggering three million new wage and salaried jobs in the next decade or so, more than any other industry.

Health firms, drug companies, hospitals and others within the current health-care system "have such a big stake in it that they can afford a whole hell of a lot of money defending that stake," says Bill Frenzel, a Republican who represented Minnesota in the House for 20 years. In short, lousy as the system may be, lots of people have a direct economic stake in it. Any wonder they don't like the idea of a leap into the unknown?

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